Pediatric Psych Flashcards
Manifestations of ADHD
Hyperactivity
Impulsivity
Inattention
Symptoms of ADHD
Cognitive functioning Academic functioning Behavioral functioning Emotional functioning Social functioning
Hyperactive ADHD Male to Female Ratio
4:1
Inattentive ADHD Male to Female Ratio
2:1
Comorbid Disorders of ADHD
Oppositional defiant disorder Conduct disorder Depression Anxiety disorder Learning disabilities
Pathogenesis of ADHD
Genetic imbalance of catecholamine metabolism in cerebral cortex
Environmental factors
Cerebral & Functional Abnormalities in ADHD Result in
Impaired executive functions
Impulsivity
Impaired Executive Functions in ADHD
Forward planning
Abstract reasoning
Mental flexibility
Working memory
Dietary influences on ADHD
Food additives Refine sugar intake Food sensitivity Essential fatty acid deficiency Iron & zinc deficiency
Associations with ADHD
Prenatal exposure to tobacco Prematurity Low birth weight Prenatal exposure to alcohol Head trauma in young children
Symptoms of ADHD
Inattentiveness
Impulsivity
Hyperactivity
Diagnosis of ADHD
Persistence, pervasiveness, and functional complications of the behavioral symptoms
Criteria for ADHD
Present in more than one setting
Persist for 6+ months
Present before age 12
Impair function in academic, social, or occupational activities
Excessive for developmental level of the child
Other mental disorders
Symptoms of Hyperactivity ADHD
Excessive Fidgetiness
Difficulty remaining seated when sitting is required
Feelings of restlessness or inappropriate running around or climbing
Difficulty playing quietly
Difficult to keep up with
Symptoms of Impulsivity ADHD
Excessive talking
Difficulty waiting turns
Blurting out answers too quickly
Interruption or intrusion of others
When are hyperactive ADHD symptoms typically observed?
By the time child reaches 4
Increase up to 7-8
After 8, symptoms decline
Adolescent- may not be noticeable
When are impulsive ADHD symptoms usually observed?
Persist throughout life
Symptoms of Inattention ADHD
Failure to provide close attention to detail, careless mistakes
Difficulty maintaining attention in play, school, or home activities
Seems not to listen, even when addressed
Fails to follow through
Difficulty organizing tasks, activities, & belongings
Avoids tasks that require mental effort
Loses objects required for tasks or activities
Easily distracted by irrelevant stimuli
Forgetfulness in routine activities
Description of the Inattentive Subtype of ADHD
Sluggish cognitive tempo and frequently appear to be daydreaming or “off task”
ADHD Symptoms Impair Function in 3 Areas
Academic
Social
Occupational
Evaluation of a Child with ADHD
Medical
Developmental
Educational
Psychosocial evaluation
Medical Evaluation of ADHD
School- learning, happy, behavioral problems, completing assignments Prenatal exposures Perinatal complications or infections CNS infection Head trauma Recurrent OM Meds Family Hx of similar behaviors
PE of ADHD Children
Measurements Dysmorphic features Neurocutaneous abnormalities Neuro exam Observation of behavior
Developmental & Behavioral Assessment of ADHD child
Onset, course, functional impact Emotional, medical,& developmental events Developmental milestones School abscess Psychosocial stressors Observation of parent-child interactions
Narrow Band Scales for ADHD
Establish presence of core symptoms
Depends on age of child, scale used, & informant
Broadband Scales Assess What for ADHD
Internalizing behaviors
Externalizing behaviors other than ADHD
Identify coexisting condition & narrow DDx
Educational Evaluation of ADHD
Teacher completes ADHD specific rating scale
Narrative summary of classroom behavior & interventions, learning patterns, & functional impairment
Copies of report cards & schoolwork
Review multidisciplinary evals
DSM-5 Criteria for ADHD
6+ symptoms of hyperactivity & impulsivity OR inattention
17+ years is 5+ symptoms of hyperactivity & impulsivity OR inattention
Hyperactivity/Impulsivity or inattention must do what according DSM-5 criteria?
Occur often Present in 2+ settings Persist for 6+ months Present before 12 years Impair function in academic, social, or occupational activities Be excessive
3 Subtypes of ADHD
Predominantly inattentivie
Predominantly hyperactive-impulse
Combined
Treatment of ADHD
Behavioral interventions
Medication
School-based interventions
Psychological interventions alone or in combination
Treatment goals of ADHD
Improved relationships with parents, teachers, siblings, or peers
Improved academic performance
Improved rule following
Indications for ADHD Referral
Coexisting psychiatric conditions
Coexisting neurologic or medical conditions
Lack of response to controlled trial of stimulant therapy or atomoxetine
Who to Refer ADHD Patients to?
Developmental behavioral pediatrician Child neurologist Psychopharmacologist Child psychiatrist Clinical child psychologist
Criteria for Initiation of Pharmacotherapy in Children with ADHD
Confirmation of ADHD 6+ years Parents approval School cooperation No sensitivity to med Normal HR & BP Seizure free Not have Tourette syndrome Not have pervasive developmental delay Not have significant anxiety Substance abuse not a concern
Medical Therapy for ADHD
Dextroamphetamine (S) Methylphenidate (S) Atomoxetine (Strattera) [NS} Buproprion (Wellbutrin) [NS] TCAs [NS] SSRIs [NS] MAOIs [NS] Alpha adrenergic agonists [NS]
Pretreatment work-up for ADHD
Comprehensive, CV focused patient hx, family hx, and PE
Vitals & assess growth
Pretreatment baseline for SE
Substance use/abuse
Prescribed to help with self-control & ability to focus
Review risks & benefits
Explanation of process & length of time
Frequency of follow-up
Information needed at follow up appt.
Behaviors/SE that family should monitor
First Line Stimulant Agents for ADHD
Ritalin Methylin Ritalin SR Metadate ER Methylin ER Ritalin LA Metadate CD Concerta Daytrana Dextrostate Dexedrine Spansule Adderall Adderall XR Focalin
Second Line Stimulant Agent for ADHD
Atomoxetine (Strattera)
Third Line Stimulant Agents for ADHD
Bupropion (Wellbutrin) Imipramine (Tofranil) Desipramine (Norpramin) Clonidine (Catapres) Guanfacine (Tenex)
Medication Management of ADHD
Start with short acting
Start low & titrate up
“Drug holidays”
ADHD Medication Black Box Warning for Stimulants
Increased risk of sudden death
CV problems
Drug dependency
ADHD Medication SE
Appetite suppression Abdominal pain Headache Insomnia Irritability Tics Associated with growth delay
Medication for Preschool Children with ADHD
Methylphenidate
3 Types of Autism Spectrum Disorders
Autistic disorder
Asperger syndrome
Pervasive developmental disorder not otherwise specified
Prevalence of Autism Spectrum Disorders
1:88 US children
Male > Female
Etiology of Autism Spectrum Disorders
Secondary to environmental, biologic, and genetic factors
Prenatal exposure to Valproic acid or thalidomide
Prematurity or low birth weight
Born to older parents
Co-occurs with other developmental, psychiatric, neurologic, chromosomal & genetic diagnosis
3 Main Areas of Function Affected by Autism Spectrum Disorders
Social interaction
Communication
Behaviors & interests
Autistic Behavior
Development delayed from birth
Sudden loss of social or language skills after normal development
Asperger’s Syndrome
Mildest form of autism Boys > Girls 3:1 Interested in single object/topic Impaired social interaction Normal to above average intelligence High risk for anxiety and depression
Pervasive Development Disorder not Otherwise Specified (PDD-NOS)
Between Autism & Asperger's Symptoms vary Impaired social interaction Fewer repetitive behaviors Later age of onset
Autism Impairments
Social functioning Language Repetitive behaviors Mental retardation Seizures
Risk Factors for Surveillance for Autism Spectrum Disorder
Sibling with ASD Parent concern Inconsistent hearing Unusual responsiveness Caregiver concern Pediatrician concern
Routine Screening for Autistic Spectrum DIsorder
Screen specifically at 18-24 months
MCHAT- modified checklist for autism in toddlers
STAT- screening tool for autism in toddlers & young children
MCHAT Screening
16-48 months Questionnaire Interest in other children Index finger to point/ indicate interest in something Oversensitive to noise Child imitate you
Red Flags for Autistic Spectrum Disorder
Regression "In their own world" Lack of showing, sharing interest or enjoyment Using caregivers hands to obtain needs Repetitive movements with objects Lack of appropriate gaze Lack of response to name Unusual prosody/pitch of vocalizations Repetitive movements or posturing
Goals of Autistic Spectrum Disorder Treatment
Minimize core features
Maximum functional independence
Maximize QOL
Maximize family function
Comprehensive Treatment
Intervention immediately
25 hours/week year round in “systematically planned, developmentally appropriate educational activities”
Low student:teacher ratio
Inclusive experience with developing peers
Educational Interventions for Autistic Spectrum Disease
Applied behavioral analysis Structured teaching Developmental Relationship focused Speech & language therapy Social skills instruction OT
Common Behavioral Issues in Autistic Spectrum Disorder
Disruption/aggression Self-injurious Eating Sleeping Toileting
Medical Management of Autistic Spectrum Disorder
Challenges in routine health care due to difficulties wit social interaction, communication, & negotiating a new & unfamiliar environment
Visit time x2
Strategies in office to promote familiarity
Associated Medical Conditions
GI: chronic constipation/diarrhea
Recurrent abdominal pain
Seizures
Sleep problems
Define Oppositional Defiant Disorder (ODD)
Psychiatric disorder that is characterized by aggressiveness and tendency to purposefully bother & irritate others
Negative, manipulative, hostile, & deviant behavior
Etiology of Oppositional Defiant Disorder (ODD)
Family history
DSM-5 Criteria for ODD
Four symptoms from categories (angry & irritable mood, argumentative & deviant behavior, vindictiveness)
Occurs with 1+ individuals who is not a sibling
Causes problems at work, school, or home
Occurs on its own
Lasts at least 6 months
Symptoms of Angry & Irritable Mood in ODD
Often loses temper
Often touchy or easily annoyed by others
Often angry & resentful
Symptoms of Argumentative & Defiant Behavior in ODD
Often argues with adults or people in authority
Often actively defies or refuses to comply with adults’ requests or rules
Often deliberately annoys people
Often blames others for mistakes or misbehavior
Symptoms of Vindictiveness in ODD
Often spiteful or vindictive
Shown spiteful or vindictive behavior at least twice in 6+ months
Prognosis of ODD
Some outgrow this
May turn into something else
May have without anything else
ODD + comorbid anxiety, ADHD, or depressive disorders
Treatment for ODD
Referral to pediatric psychiatrist
Meds for co-morbid disorders
Behavioral therapy
Parental therapy for setting clear boundaries
Define Conduct Disorder (CD)
Group of behavioral and emotional problems in children
Significant difficulty following rules & behaving in a socially acceptable way
“Bad” kids or delinquents
Factors that Contribute to Conduct Disorder (CD)
Brain damage Child abuse Neglect Genetic vulnerability School failure Traumatic life experiences
Conduct Disorder vs. ODD
Conduct disorder worse version of ODD
ODD have worse social skills
ODD do better in school
CD most serious childhood psychiatric disorder
Co-morbid Conditions Associated with CD
Depression/anxiety disorders PTSD Substance abuse ADHD Learning problems Bipolar disorder Tourette's syndrome
Conduct Disorder Characterized by
Aggression to people & animals
Destruction of property (arson)
Deceitfulness, lying or stealing
Serious violations of the rules
Characteristics of CD for Aggression to People & Animals
Bullies, threatens or intimidates Physical fights Use of weapons to harm others Physically cruel to people or animals Steals Forces others into sexual acts
Treatment for Conduct Disorder
Referral to Psychiatrist for behavioral therapy, psychotherapy, parental support & training, meds for comorbid conditions
Prognosis of Conduct Disorder
Similar problems into adulthood
Likely to have personality disorder
Abuse of substances 4 years later
Cigarett smoking
DSM-5 for Depression
Depressed mood
Diminished interest or loss of pleasure in almost all activities
Sleep disturbance
Weight change
Appetite disturbance
Failure to achieve weight gain
Decreased concentration or indecisiveness
Suicidal ideation
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or appropriate guilt
Medical Evaluation to Rule Out Etiologies
Infection Medication Endocrine disorder Tumor Neurologic disorder Misc. disorders
Acronym for Signs/Symptoms of Major Depression
SIG
E
CAPS
Signs & Symptoms of Major Depression
S- sleep disturbance I- interests G- guilt E- energy C- concentration problems A- appetite change P- pleasure S- suicidal though/actions
Treatment for Depression
Psychotherapy
Medical therapy
Combination of both
Medical Treatment of Depression with SSRIs
Fluoxetine (Prozac)
Escitalopram (Lexapro)
SSRI Black Box Warning
Increase suicide risk
Weigh risks vs. benefit
